Type of publication:
Conference abstract

Author(s):
Iyen B.; Qureshi N.; Roderick P.; *Capps N.; Durrington P.N.; McDowell I.F.W.; Cegla J.; Soran H.; Schofield J.; Neil H.A.W.; Kai J.; Weng S.; Humphries S.E.

Citation:
Atherosclerosis Plus. Conference: HEART UK 35th Annual Medical & Scientific Conference. Virtual. 49(Supplement 1) (pp S4-S5), 2022. Date of Publication: October 2022

Abstract:
Background: Measures of social deprivation are associated with higher cardiovascular diseases (CVD) morbidity and mortality. To determine if this is also seen in subjects with Familial Hypercholesterolaemia (FH), CVD morbidity has been examined in participants in the UK primary care database (CPRD) and in the UK Simon Broome (SB) register using linkage to the UK secondary care Hospital Episodes Statistics (HES). Method(s): A composite CVD outcome was analysed (first HES outcome of coronary heart disease, myocardial infarction, stable or unstable angina, stroke, TIA, PVD, heart failure, PCI and CABG). The measure of socio-economic status/deprivation used was the English index of multiple deprivation (IMD). Cox proportional hazards regression estimated hazards ratios (HR) for incident CVD and mortality [95% CI] in each IMD quintile. <br/>Result(s): We identified 4,309 patients with FH in UK CPRD primary care database (followed from 1988 to 2020), free from CVD, and 2988 SB register participants, with linked secondary care HES records. In both groups, the prevalence of FH was considerably lower in the most deprived quintile (60% in CPRD and 52% in SB). CPRD patients in the most deprived quintile (IMD-5) had the highest prevalence of obesity and of smoking compared to those from IMD quintiles 1,2,3 and 4 (p-value for trend, all <0.001). Compared to least deprived, the most deprived individuals had the highest risk of composite CVD (unadjusted HR 1.71 [CI 1.22-2.40]), however, on adjustment for smoking and alcohol consumption, there were no statistical differences in CVD risk between socio-economic groups. In the FH Register patients there was an increase in the incidence rates and hazards ratios for composite CVD with increasing quintiles of deprivation. After adjustment for age, sex, smoking and alcohol consumption, this effect remained statistically significant (quintile 5 vs 1, HR = 1.83 [1.54-2.17]. Conclusion(s): Patients with FH are underdiagnosed in lower socio-economic groups. In both CPRD and the SB Register the most deprived FH patients had the highest risk of CVD and mortality, but in CPRD but not in the SB register this was largely explained by smoking and alcohol consumption. Clinicians should adopt more effective strategies to detect FH in lower socio-economic groups, and to optimise risk factor management and to support lifestyle changes and medication adherence for this group.

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Type of publication:
Conference abstract

Author(s):
Graby J.; Sellek J.; Bayly G.; Avades T.; *Capps N.; Shipman K.; Mbagaya W.; Luvai A.; Khavandi A.; Loughborough W.; Hudson B.; Downie P.; Rodrigues J.;

Citation:
Heart. Conference: British Cardiovascular Society Annual Conference, BCS 2022. Manchester United Kingdom. 108(Supplement 1) (pp A135-A136), 2022. Date of Publication: June 2022.

Abstract:
Introduction Dyslipidaemia accelerates atherosclerosis. Patients with genetic dyslipidaemias, Familial Hypercholesterolaemia (FH) being the most common, are at heightened risk of premature cardiovascular events. However, this risk is heterogeneous within identical genotype diseases, and modifiable with treatment. Coronary imaging identifies subclinical atherosclerosis, personalises risk stratification and treatment targets. Coronary artery calcium scoring (CACS) is first-line for primary prevention. However, calcification is a late-stage process in CAD pathogenesis and the CACS has low specificity in young patients with severe FH. CT coronary angiography (CTCA) may identify non-calcific CAD and high risk plaque (HRP) features unseen with CACS. This study aimed to quantify the impact of CTCA vs traditional CACS on clinical management in real-world asymptomatic Lipid Clinic patients. Methods A retrospective single-centre review of asymptomatic Lipid Clinic electronic patient records with both CACS and CTCA from May 2019 to December 2020. A vignette was compiled for each patient providing all relevant clinical data. CACS was recorded as Agastston score and CTCA as the Coronary Artery Disease – Reporting and Data System (CAD RADS) grading of anatomical stenosis with a modifier for HRP features.Findings were compiled into an anonymised online survey which Consultant Biochemists from across the UK were invited to complete. Data was revealed in a stepwise fashion to the participating clinician: (i) vignette only, (ii) CACS, and (iii) CAD RADS. Clinicians were asked their lipid target and management after each data-point was unblinded. Background information on CACS and CTCA result interpretation was provided prior to participation. Statistical analysis was performed using SPSS v.21 and significance was defined as two-tailed p<0.05. Results 45 asymptomatic patients (55+/-9 years, 49% female) were included. 7 Consultant Biochemists from 6 institutions (4 [67%] tertiary/teaching Hospitals and 2 [33%] district general Hospitals) participated.CACS and CAD RADS assessment of disease burden is presented in Figure 1, with CTCA re-classifying CAD severity vs CACS in 28/45 (62%) patientsLipid targets were altered significantly more frequently with CTCA vs CACS (19% vs 12%; chi2 57.0, p<0.005), even after CACS result available (Figure 2). The LDL target selected was altered by CACS in 12%, and in a further 19% when CAD RADS result was unblinded, which was statistically significant (c2 57.0, p<0.005). This finding was consistent across FH and non-FH patients. Increasing CACS and CAD RADS severity were significantly associated with change in lipid target (c2 54.2, p<0.001; chi2 27, p<0.001), the latter even after a high CACS result was available, as did presence of HRP (chi2 9.3, p=0.002). Conclusion In high-risk asymptomatic dyslipidaemia, CTCA alters treatment targets beyond CACS by demonstrating higher CAD severity burden and HRP. This may differentiate high risk and very high risk patients in an important population.

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Type of publication:
Conference abstract

Author(s):
*Asad M.; Younas W.; *Kazi S.I.; Alaguraja P.; *Makan J.

Citation:
Heart. Conference: British Cardiovascular Society Annual Conference, BCS 2022. Manchester United Kingdom. 108(Supplement 1) (pp A74-A75), 2022. Date of Publication: June 2022.

Abstract:
Background Inappropriate use of telemetry results in the overuse of limited resources, disrupted provider workflow, higher costs of care, and false alarms with resultant alarm fatigue. Moreover, identifying a useful implementation blueprint is an important component of promoting its appropriate use. Telemetry can influence patient experience during their stay as potentially it can disturb sleep, contribute to delirium, and increase patient frustration and anxiety. We stipulate that even minor adjustments to monitoring practices can influence optimised patient care. We aimed to evaluate the co-existing standards of practice regarding use of telemetry across Shrewsbury and Telford Hospital NHS Trust (SaTH). We implemented a patient-centred approach towards quality improvement by incorporating record of patient experience as a tool to guide effective use of this limited resource across our district general hospital settings. Methods Patients across two hospital sites were selected to conduct a prospective health service evaluation related to the use of telemetry. A likert scale survey was conducted to record patient perspective of telemetry monitoring including a section with an opportunity to provide feedback towards service improvement. The data of patients receiving telemetry was collected from December 2021 to February 2022.American Heart Association (AHA) consensus statement for remote electrocardiographic monitoring was utilized to evaluate the proposed indication for telemetry. However, the rating system helped group patients receiving telemetry monitoring as Class I (definitely indicated), Class II (maybe indicated), or Class III (not indicated). Clinical notes and electronic telemetry system was employed to record parameters including patient demographics; presenting complaint; class (I-III) of indication; whether an indication for telemetry was documented; the length of telemetry; and the details of any significant events that occurred during monitoring including escalation. Where possible, patients were asked to anonymously provide feedback via set questionnaire focusing on quality of care received by the patient. Result(s):Among the 30 patients who were included in our analysis, 7 were females and the average age in our cohort was found to be 72.8. In about 56% of the patients, there was no clear indication mentioned in the clinical notes regarding continuation/discontinuation of telemetry. Based on proposed indication, about 36.66% (11 patients out of which 2 were female) were identified to be at significant risk of an immediate life-threatening arrhythmia (Class I). Among this group, 2 patients were reported to have significant arrhythmia event necessitating treatment. Further analysis revealed that from our cohort, 46.66% (14 patients) had a Class II indication for their telemetry monitoring out of which only 2 patients had a significant event recorded. However, only 16.66% (5 patients) were found to meet the eligibility for Class III indications and none of them encountered a significant arrhythmia. From anonymously filled patient questionnaires, around two-third of the patients reported not being informed about the utility of telemetry and its predicted duration of stay. One-third of patients reported the device to be inconvenient, intrusive and heavy. Conclusions To accomplish a sustainable improvement, a patient-centred approach should be exercised to help identify the gaps in quality of care delivered. Our analysis showed that significant number of patients received telemetry when it was not clinically indicated. The proposed interventions include adopting formal request process for telemetry, predicting its duration, use of patient education tools and exploring compatibility of telemetry device used. Larger scale studies are required to gain more insight into the appropriateness and impact of telemetry in a hospital setting.

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Type of publication:
Conference abstract

Author(s):
Iyen B.; Qureshi N.; Roderick P.; *Capps N.; Durrington P.N.; McDowell I.F.W.; Cegla J.; Soran H.; Schofield J.; Neil H.A.W.; Kai J.; Weng S.; Humphries S.E.

Citation:
Atherosclerosis Plus. Conference: HEART UK 34th Annual Medical & Scientific Virtual Conference. Virtual, Online. 43(Supplement) (pp S5), 2021. Date of Publication: September 2021.

Abstract:
Background: Previous studies of the Simon Broome (SB) FH register reported that, compared to the low-intensity statin period (1992-2008), the standardised cardiovascular disease (CVD) mortality ratio in the high-intensity statin period (2009-2015) was 22% lower in men but 115% higher in women. Linkage of the register with Hospital Episodes Statistics (HES) data has now enabled prospective evaluation of CVD morbidity based on inpatient care. Method(s): Standardised Morbidity Ratios (SMbR) compared to age and sex-matched UK primary care patients were calculated [95% confidence intervals] for risk of composite CVD (first HES outcome of CHD, MI, stable or unstable angina, stroke, TIA, PVD, heart failure, PCI and CABG) in men and women under and over the age of 50 years. Result(s): 2,988 (52.5% women) SB register participants had HES records. The SMbR was higher in women than men in both age groups and during both time periods. Compared to 1997-2007, in both men and women aged <50 years the SMbR fell significantly in the 2008-2017 period (8.7[7.3-10.3] vs 17.9[15.7-20.5] and 12.8[10.4-15.7] vs 20.8[17.1-25.4] respectively. By contrast in both sexes in those >50 years in the later time period there was no significant reduction in CVD-admission incidence rates or in SMbR (Men, 6.6[5.3-8.2] vs 5.8[5.0-6.8], Women, 9.2[7.8-10.7] vs 7.5 [6.6-8.5]). Conclusion(s): While the rate of CVD morbidity due to FH has encouragingly fallen significantly over time in both sexes aged <50 years, it has not done so in those >50. This emphasises the importance of early identification and optimal lipid-lowering throughout life for subjects with FH. Funded by the NIHR HTA project 15/134/02 and BHF grants RG3008 and PG008/08.

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